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Membership Registration Form

The form collects personal details such as name, date of birth, address, contact information, occupation, and emergency contact details. The applicant nominates their mother Priscilla Ojumbo and father Moses Ojumbo as beneficiaries. Additional family members listed are the applicant's parents. At the end, the applicant agrees to abide by the SACCO bylaws and signs and dates the form.

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Trevor Wandera
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831 views2 pages

Membership Registration Form

The form collects personal details such as name, date of birth, address, contact information, occupation, and emergency contact details. The applicant nominates their mother Priscilla Ojumbo and father Moses Ojumbo as beneficiaries. Additional family members listed are the applicant's parents. At the end, the applicant agrees to abide by the SACCO bylaws and signs and dates the form.

Uploaded by

Trevor Wandera
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd

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212 STAFF SACCO MEMBERSHIP REGISTRATION FORM

Please use Bold/Capital letters in filling this form.

1. PERSONAL PARTICULARS

SURNAME: WANDERA OTHER NAMES: TREVOR ALVIN

DATE OF BIRTH (D,M,Y): 20/10/1997 MEMBERSHIP NUMBER:

REGISTRATION FEE: MARITAL STATUS: SINGLE

OCCUPATION/PROFESSION: INVESTOR RELATIONS EMPLOYER: MTN UGANDA


ANALYST

RESIDENTIAL ADDRESS:: NANSANA, KAMPALA POSTAL ADDRESS: KAMPALA, UGANDA

E-MAIL ADDRESS: WANDERATREVOR@[Link]

TELEPHONE – MOBILE: 0776314276 TELEPHONE - FIXED

2. SAVINGS BENEFICIARIES DECLARATION

In the event of death, I hereby nominate the following persons to be considered for the receipt of all benefits less liabilities
payable to me, under the 212 Staff SACCO.

NB; Persons under the age of 18 years should not be nominated; instead a trustee should be considered:
SURNAME: OJAMBO OTHER NAMES: PRISCILLA

RELATIONSHIP: MOTHER DATE OF BIRTH (D,M,Y)

OCCUPATION/PROFESSION: BUSINESSWOMAN EMPLOYER: SELF-EMPLOYED

RESIDENTIAL ADDRESS: NANSANA, UGANDA POSTAL ADDRESS: KAMPALA, UGANDA

E-MAIL ADDRESS: TRIPLETEE18@[Link]

TELEPHONE – MOBILE: 0772212865 TELEPHONE - FIXED

In the event that the above named beneficiary is totally not available/ is totally absent , I nominate:

SURNAME: OJAMBO OTHER NAMES: MOSES

RELATIONSHIP: FATHER DATE OF BIRTH (D,M,Y):23/12/1968

OCCUPATION/PROFESSION: ADMINISTRATOR EMPLOYER: PPDA

RESIDENTIAL ADDRESS: NANSANA, UGANDA POSTAL ADDRESS: KAMPALA, UGANDA

E-MAIL ADDRESS: MOJAMBO68@[Link]

TELEPHONE – MOBILE: 0787570002 TELEPHONE – FIXED:

.212 Staff SACCO Page 1


3. SAVINGS BENEFICIARIES PARTICULARS (Limited to Spouse, Biological Children and Biological Parents)

FIRST AND SURNAME RELATIONSHIP AGE DATE OF BIRTH

FATHER 54 23/12/1968

MOSES OJAMBO

MOTHER 51 20/05/1971

PRISCILLA OJAMBO

DECLARATION:

I hereby submit my application to join membership of the 212 Staff‐SACCO and agree to abide by the
Bye-laws and / or any amendments thereof.

.......................................................... .........30/03/2023............................
Member’s Signature Date

FOR OFFICAL USE ONLY

I certify that the above information is correct.

Name of the Registration Officer…………………………………………………………

Signature………………………………………………… Date…………………………

.212 Staff SACCO Page 2

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